Disorders

You are enough. Always have been and always will be…

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“He who knows that enough is enough will always have enough.” ~ Lao Tzu

For years my life was defined by deep feelings of inadequacy as well as concurrent actions of striving to keep those feelings at bay. Even as a young child, I felt nothing I did was good enough, and I can still recall feelings of intense anxiety, sometimes terror, at simply waking up and knowing I had to go to school. While my parents meant well, I was inculcated with the belief that to be loved meant having to prove your worth each and every day, which meant doing things in a certain way—staying quiet, doing what you were told, getting good grades, taking certain subjects.  In other words, I was given a supposed checklist of success, which would supposedly lead to this elusive state called “happiness.”

I was taught to be competitive, to believe that my self-worth was directly tied to accomplishment.  I could not be of value unless I achieved something. This is a belief system embraced by many, and for me, it only served to deepen the feelings of emptiness and downright devastation that I experienced, especially if I failed at something.  When one lives in a constant state of competition, there is no such thing as ever being good enough.  One lives in a constant fear that you NEVER will be good enough. Even as I continually achieved and collected accolades, I suffered from constant panic attacks, chronic anxiety and depression.  Therapy and anti-depressants would provide short-lived respite.

However, even as I spent most of waking time dedicated to “doing,” part of me was suspicious of what the point exactly was to all this “doing.”  A secret voice was always asking, “Is this all there is?”  Part of me was deeply ashamed that this voice even existed. After all, society was reinforcing that I was doing things the “right way.”  I dutifully checked off the items on my checklist of success, completely believing that once I completed each task, I would be closer and closer to that state called “happiness.”  However, with each accomplishment, I only seemed to be further and further away from where I wanted to be. A part of me resigned myself to believing that perhaps what I really wanted could never be attained, that it was elusive and outside myself.  But even as I tried to give into resignation, that voice and its question “Is this all there is?” continued to plague me.  I had become an adult and done everything that was expected of me.  And I was completely miserable.

“Is this all there is?” became an accusation.  But I busied myself with tasks to which I attached great importance.  I cooked gourmet meals.  I traveled to faraway places.  I did yoga.  I went through the motions of what a good life was supposed to be, never realizing in all those years that what I had longed for resided within myself.  My self-worth still resided in the external— from accomplishments and material possessions, in the need for validation from others.  It never occurred to me that I could give myself validation because I had never been taught that.

I remember back in 2001 discovering a book by Thich Nhat Hanh, in which he spoke about suffering.  It struck a chord with me, but I could not understand it.  For he said to lessen suffering in the world, you had to reduce suffering within yourself.  That concept seemed completely foreign to me. I did not understand how lessening MY suffering could possibly lessen the suffering of others. So even when we are well-meaning in focusing on the suffering of others, it only serves to distract from addressing what needs to change within ourselves.

“We must be willing to let go of the life we planned so as to have the life that is waiting for us.” ~ Joseph Campbell

Fast forward to the present, I now realize that we cannot possibly give or receive love without knowing love within ourselves first.  And how did I finally understand this?  It was when I heard the words, “Who you are is enough.”  I don’t know from whom or exactly when I heard this, but the concept was so revolutionary to me that I shed tears.  And for the first time, I felt free.  I have heard this mantra echoed numerous times from many spiritual teachings and teachers since hearing it the first time, but I finally understood what Thich Nhat Hanh meant.

I have dedicated the past few years to releasing my old belief systems related to worthiness. When the inner voice asked the question “Is there all there is?”, it was really asking, “Are you good enough?”  And the answer has been and always will be, “I am enough.”

You are enough. Always have been and always will be…

Do you think your life would look any different if you knew that you were enough?

Training to recognise the early signs of recurrence in schizophrenia.

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The lifetime prevalence of schizophrenia is just less than 1% with onset usually occurring during adolescence or early adulthood. People with schizophrenia have an increased risk of suicide and physical illness, as well as impaired occupational and social functioning. A large proportion experience a cyclical pattern of illness, with periods of acute psychotic episodes followed by stable periods of full or partial remission, although these are often accompanied by the presence of residual symptoms.

This Cochrane Review from February 2013 examines whether one particular aspect of psychological treatment for schizophrenia – training in the detection of early signs of relapse – might help people with schizophrenia and those who care for them to work towards a better outcome. The intention was to try to separate the effects of this training from other psychological interventions, but only one of the included studies examined this. All the studies looked at the effects of training provided to people with schizophrenia.

In total, 34 randomised trials were available for the review. These had been reported in 41 publications and included more than 3500 participants. There was a certain symmetry to these studies, with 11 from North America, 11 from Europe and 11 from the East Asia. The remaining study was from Australia. The primary outcomes for the review were relapse and rehospitalisation. The authors conducted analyses of whether or not people experienced one of these events and, where possible, they also looked at the time to the event. Almost all the trials randomised participants individually, but two of the studies used a cluster approach.

Some of the included studies concentrated on early warning signs as the primary intervention, while others had this as part of a wider programme. There were also variations in how the interventions were implemented, what they focused on and who delivered the therapy. For example, the practitioners in some trials were psychologists, while doctors or nurses were involved in other trials. A further complication was that the definition of ‘relapse’ varied across studies, ranging from the onset of symptoms to admission to hospital. Coupled with this considerable heterogeneity, when the authors assessed the quality of the evidence, they judged that it was ‘very low’.

With these cautions in mind, the review found that significantly fewer people relapsed with early warning signs interventions than with usual care (23% versus 43%; risk ratio [RR]: 0.53, 95% confidence interval [CI}: 0.36 to 0.79), based on data from 1502 participants in 15 trials. The risk of re-hospitalisation was also significantly lower with early warning signs interventions compared to usual care (19% versus 39%; RR: 0.48, 95% CI: 0.35 to 0.66), in 15 trials with 1457 participants. Six trials (550 participants) could be included in the analysis of time to relapse, and this was found to be not significantly different between the intervention groups, and there was also no significant difference in time to re-hospitalisation (6 trials, 1149 participants). The findings for participants’ satisfaction with care and economic costs were inconclusive because of a lack of evidence.

The review concludes that early warning signs interventions may have a positive effect on the proportions of people who relapse and who are re-hospitalised, but that the overall quality of the evidence makes it unclear whether the interventions would have similar effects outside trials and suggests that further research is very likely to alter the current estimates. There is also doubt about whether the early warning signs interventions would be effective on their own, given that they were used alongside other psychological interventions in the trials.

The authors note that the interventions might be cost-effective due to reduced hospitalisation and relapse rates, but highlight the importance of further research, of high or moderate quality, before mental health services should routinely provide psychological interventions involving the early recognition and prompt management of early warning signs to adults with schizophrenia. They emphasise the need for future randomised trials to be adequately-powered, designed in ways that will minimise the risk of bias and reported in ways that enhance transparency. They also stress that these studies should evaluate resource costs and resource use, alongside efficacy outcomes and other outcomes that are important to people with serious mental illness and their carers.

Soure: Cochrane Library

Abdominal Pain in Childhood Linked to Anxiety, Depression in Young Adulthood.

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Children with medically unexplained “functional abdominal pain” face increased risks for anxiety and depression in adolescence and young adulthood, according to a Pediatrics study.

Researchers prospectively followed some 330 children with functional abdominal pain and 150 age-matched controls without pain into adolescence and young adulthood (mean age at follow-up, 20 years). They found that children who’d had abdominal pain at baseline were significantly more likely than controls to meet criteria for lifetime anxiety disorders (51% vs. 20%) and current anxiety disorders (30% vs. 12%) at follow-up. In most cases, anxiety preceded the onset of abdominal pain. In some cases, anxiety persisted after pain had resolved.

The pain group was also more likely than the control group to meet criteria for lifetime depression at follow-up (40% vs. 16%); depression usually began after abdominal pain.

“These data underscore the importance of a biopsychosocial approach to [functional abdominal pain] that includes screening for anxiety and depression,” the researchers conclude.

Source: Pediatrics

Fertility treatment and risk of childhood and adolescent mental disorders: register based cohort study.

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Abstract

Objective To assess the mental health of children born after fertility treatment by comparing their risk of mental disorders with that of spontaneously conceived children.

Design Prospective register based cohort study.

Setting Nationwide register based information from Danish National Health Registers cross linked by a unique personal identification number assigned to all citizens in Denmark.

Participants All children born in Denmark in 1995-2003 with follow-up in 2012 when the children were aged 8-17; 33 139 children were conceived after fertility treatment and 555 828 children were born after spontaneous conception.

Main outcome measures Absolute risks and hazard ratios for overall and specific mental disorders estimated with adjustment for potential confounding variables. Estimated association between the risk of mental disorders and subtypes of procedures, hormone treatments, gamete types, and cause of infertility.

Results The risk of mental disorders in children born after in vitro fertilisation or intracytoplasmic sperm injection was low, and was no higher than in spontaneously conceived children, except for a borderline significant increased risk of tic disorders (hazard ratio 1.40, 95% confidence interval 1.01 to 1.95; absolute risk 0.3%). In contrast, children born after ovulation induction with or without insemination had low but significantly increased risks of any mental disorder (1.20, 1.11 to 1.31; absolute risk 4.1%), autism spectrum disorders (1.20, 1.05 to 1.37; 1.5%), hyperkinetic disorders (1.23, 1.08 to 1.40; 1.7%), conduct, emotional, or social disorder (1.21, 1.02 to 1.45; 0.8%), and tic disorders (1.51, 1.16 to 1.96; 0.4%). There was no risk systematically related to any specific type of hormone drug treatment.

Conclusions There was a small increase in the incidence of mental disorders in children born after ovulation induction/intrauterine insemination. Children born after in vitro fertilisation/intracytoplasmic sperm injection were found to have overall risk comparable with children conceived spontaneously.

Discussion

In this large long term follow-up of an unselected cohort of children conceived after fertility treatment, we found a systematically small increased risk of mental disorders in children born after induced ovulation/intrauterine insemination compared with spontaneously conceived children. When we considered the diagnoses in categories of mental disorders, there was a significant increased risk of autistic spectrum disorders, hyperkinetic disorders, tic disorders, and conduct, emotional, or social disorders. In contrast, beside a borderline significantly increased risk of tic disorders, we found no association between conception after IVF/ICSI and risk of mental disorders in childhood or adolescence. There were no systematic associations between cryopreserved embryos or gametes, types of hormones, or cause of infertility and risk of mental disorders.

What is known on this topic

  • Children born after fertility treatment have an increased risk of some perinatal outcomes such as low birth weight, shorter gestational age, and congenital malformations
  • The risk of malformations is related to the subfertility rather than the procedures or treatments
  • Long term development is sparsely investigated and few have studied children born after induced ovulation
  • The overall long term development of children born after IVF/ICSI is comparable with that of children conceived spontaneously
  • Children born after induced ovulation seem to have a small increased risk of autism, hyperkinetic disorders, conduct, emotional or social disorder, and tic disorders, but the absolute risks are low
  • Source: BMJ

What this study adds

 

Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care.

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Abstract

Objective To investigate whether an intervention to improve treatment of depression in older adults in primary care modified the increased risk of death associated with depression.

Design Long term follow-up of multi-site practice randomized controlled trial (PROSPECT—Prevention of Suicide in Primary Care Elderly: Collaborative Trial).

Setting 20 primary care practices in New York City, Philadelphia, and Pittsburgh, USA, randomized to intervention or usual care.

Participants 1226 participants identified between May 1999 and August 2001 through a two stage, age stratified (60-74; ≥75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of patients who screened negative.

Intervention For two years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm based care for depression, offering psychotherapy, increasing antidepressant dose if indicated, and monitoring symptoms, adverse effects of drugs, and adherence to treatment. This paper reports the long term follow-up.

Main outcome measure Mortality risk based on a median follow-up of 98 (range 0.8-116.4) months through 2008.

Results In baseline clinical interviews, 396 people were classified as having major depression, 203 had clinically significant minor depression, and 627 did not meet criteria for depression. At follow-up, 405 patients had died. Patients with major depression in usual care were more likely to die than were those without depression (hazard ratio 1.90, 95% confidence interval 1.57 to 2.31). In contrast, patients with major depression in intervention practices were at no greater risk than were people without depression (hazard ratio 1.09, 0.83 to 1.44). Patients with major depression in intervention practices, relative to usual care, were 24% less likely to have died (hazard ratio 0.76, 0.57 to 1.00; P=0.05). Preliminary data on cause of death are provided. No significant effect on mortality was found for minor depression.

Conclusions Older adults with major depression in practices provided with additional resources to intensively manage depression had a mortality risk lower than that observed in usual care and similar to older adults without depression.

What is already known on this topic

  • Prospective studies have consistently shown a relation between depression and increased mortality in older adults
  • No randomized trials have reported that a depression management program can decrease risk
  • A 24% lower mortality risk was seen after a median of 98 months among patients with major depression in practices provided with resources for depression care management compared with usual care
  • The decline in mortality was across all causes of death, but with fewer deaths from cancer among people with major depression in intervention practices
  • A depression care manager working with primary care physicians to provide algorithm based care for depression can mitigate the detrimental effects of depression on mortality

What this study adds

 

Source: BMJ

 

 

nitial9 �ta � spacing:0px’ id=p-70>Our patients presented relatively late after the onset of illness, a median of five days overall (seven days for H5N1). Despite administration of oseltamivir, about 30% of those enrolled remained positive for viral RNA (the primary endpoint) after five days of treatment. Timing of oseltamivir treatment is important as several studies have shown that early treatment confers greater virological and clinical benefits.4 5 6 32 33 34 In particular, later viral clearance has been noted with delayed treatment with oseltamivir compared with treatment within two to three days after onset of symptoms in observational reports from patients with H1N1-pdm09, especially those with severe illness.35 36 37 38 39 40 In the current trial, 73 (22.4%) patients presented within three days of illness, but even in this subpopulation, double dose oseltamivir was not associated with more rapid viral RNA clearance. Over a quarter of patients received neuraminidase inhibitors before enrolment, which could have influenced the effect size and contributed to the low proportion of patients shedding virus at day five in both treatment groups.

 

Although viral RNA detection in samples from the upper respiratory tract might not accurately reflect viral replication in the lower respiratory tract, especially in those with severe illness,39 prolonged viral RNA detection in upper respiratory tract samples has been shown to correlate with inpatient morbidity and prolonged hospital stay. In our study viral detection on day five was observed at about twofold the frequency in those meeting the criteria for clinical failure, although lack of clinical failure was not a surrogate for cessation of viral detection. Thus in our study the delays in starting treatment with oseltamivir also probably contributed to the substantial rates of admission to intensive care (18%), use of supplemental oxygen (30%), mechanical ventilation (12%), and mortality in hospital of 6.4%. Although our study was not placebo controlled for ethical reasons, other studies indicate that early oseltamivir treatment in people with severe influenza is associated with both clinical benefits and more rapid viral clearance from upper respiratory tract samples.

Possible reasons for findings

It is unclear why double dose oseltamivir does not seem to offer benefit over standard dose in patients with severe influenza. Blood trough concentrations of oseltamivir carboxylate from 75 mg or 150 mg twice daily in influenza exceed the IC50 (inhibitory concentration) of influenza viruses.42 43 Inhibition of viral neuraminidase by oseltamivir might be a saturable process, and maximal inhibition might be achieved with a standard dose; exceeding these concentrations might not produce an additional clinical or virological effect. In this regard, a randomised oseltamivir controlled study of intravenous peramivir (BioCryst Pharmaceuticals, Durham, NC), which reaches over 20-fold higher peak blood concentrations of active metabolite than oseltamivir carboxylate, found similar viral reductions in patients with influenza A virus admitted to hospital.44 Further studies of peramivir and other intravenous neuraminidase inhibitors currently in progress should provide additional evidence regarding this hypothesis.

Infection with avian H5N1 virus, higher baseline viral load, and severity of disease were independently associated with longer viral RNA detection. The association between avian H5N1, severe illness, and prolonged shedding has been well described.14 The clearance kinetics of influenza viruses, both without antiviral treatment and with oseltamivir treatment,32 41 could explain longer viral RNA detection with higher baseline viral loads. It is unclear whether the independent association with disease severity might be related to impaired mechanisms of viral clearance or higher intrinsic rates of viral replication or both in these patients. Severe chronic comorbidities are seen commonly in industrialised countries and are related to prolonged viral shedding but most of our patients lacked these comorbidities.40 41

The heterogeneous population characteristics, geographical differences in recruitment (most patients were from Vietnam but there were no significant differences between Vietnam and other sites), and the variety of infecting viruses in our trial reflect the clinical circumstances in South East Asia during our study but might be viewed as a limitation. Most of these patients were children and had low or normal BMI, and for all patients only about a fifth reported a chronic underlying medical condition. Thus, our findings are applicable primarily to the region where the study was conducted and other settings with similar characteristics of influenza epidemiology. We did not have many adults in our study and results were inconclusive but indicate no difference in efficacy between the two oseltamivir regimens. We would caution the extension of our results to, for example, morbidly obese adults with severe influenza and those who could have underlying chronic illnesses. We conducted several statistical comparisons and inevitably subgroup analyses involved small numbers; thus power was limited and some significant results could have resulted by chance. Additionally, as all patients were randomised to an active treatment, our study was not designed to evaluate the efficacy of oseltamivir in severe influenza nor in H5N1 infections. This large randomised trial did, however, examine an important clinical and public health question and showed a lack of a clinical or virological benefit of double dose compared with standard dose oseltamivir in patients admitted to hospital with severe influenza. Our results and other observational reports from avian H5N110 and H1N1-pdm0911 36 infections do not support routine use of double dose oseltamivir to treat severe influenza. These findings have implications for both clinical management and pandemic preparedness including during the current H7N9 epidemic.16 17 18

What is already known on this topic

  • Clinical trials in patients with uncomplicated influenza have shown that treatment with oseltamivir has clinical and virological benefit when administered within 48 hours of onset of symptoms
  • Observational studies in severe influenza have shown that oseltamivir treatment, if given early, is associated with reduced mortality and shorter length of hospital stay. Reduced mortality has also been reported for patients with H5N1 influenza treated with oseltamivir
  • Several authorities have suggested the use of double dose oseltamivir for severe influenza, although there is no clinical evidence to support this
  • In the largest randomised trial on the treatment of severe influenza, no clinical or virological benefit of double dose oseltamivir over standard dose was found
  • These findings have implications for both clinical management of severe influenza and for pandemic preparedness of emerging influenza viruses including the current H7N9 epidemic

What this study adds

 

 

Source: BMJ

 

 

Parental depression, maternal antidepressant use during pregnancy, and risk of autism spectrum disorders: population based case-control study.

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Abstract

 

Objective To study the association between parental depression and maternal antidepressant use during pregnancy with autism spectrum disorders in offspring.

Design Population based nested case-control study.

Setting Stockholm County, Sweden, 2001-07.

Participants 4429 cases of autism spectrum disorder (1828 with and 2601 without intellectual disability) and 43 277 age and sex matched controls in the full sample (1679 cases of autism spectrum disorder and 16 845 controls with data on maternal antidepressant use nested within a cohort (n=589 114) of young people aged 0-17 years.

Main outcome measure A diagnosis of autism spectrum disorder, with or without intellectual disability.

Exposures Parental depression and other characteristics prospectively recorded in administrative registers before the birth of the child. Maternal antidepressant use, recorded at the first antenatal interview, was available for children born from 1995 onwards.

Results A history of maternal (adjusted odds ratio 1.49, 95% confidence interval 1.08 to 2.08) but not paternal depression was associated with an increased risk of autism spectrum disorders in offspring. In the subsample with available data on drugs, this association was confined to women reporting antidepressant use during pregnancy (3.34, 1.50 to 7.47, P=0.003), irrespective of whether selective serotonin reuptake inhibitors (SSRIs) or non-selective monoamine reuptake inhibitors were reported. All associations were higher in cases of autism without intellectual disability, there being no evidence of an increased risk of autism with intellectual disability. Assuming an unconfounded, causal association, antidepressant use during pregnancy explained 0.6% of the cases of autism spectrum disorder.

Conclusions In utero exposure to both SSRIs and non-selective monoamine reuptake inhibitors (tricyclic antidepressants) was associated with an increased risk of autism spectrum disorders, particularly without intellectual disability. Whether this association is causal or reflects the risk of autism with severe depression during pregnancy requires further research. However, assuming causality, antidepressant use during pregnancy is unlikely to have contributed significantly towards the dramatic increase in observed prevalence of autism spectrum disorders as it explained less than 1% of cases.

Discussion

A maternal history of depression was associated with a higher risk of autism in offspring, but there was no evidence of a relation with paternal depression. These associations were largely limited to children of mothers who reported using antidepressants at the first antenatal interview. The increased risk was observed with SSRIs as well as with other monoamine reuptake inhibitor antidepressants. All these increased risks seemed to be confined to autism spectrum disorders without intellectual disability and persisted after adjustment for several confounding factors.

What is already known on this topic

  • Parental depression is considered a risk factor for autism spectrum disorder (autism) but meta-analytical evidence is inconclusive
  • One study suggested an association between prescriptions for selective serotonin reuptake inhibitors (SSRIs) during pregnancy and autism in offspring
  • This suggestion may have led to a preferential use of other antidepressants over SSRIs during pregnancy
  • A maternal but not paternal history of depression was associated with a higher risk of autism in offspring
  • The increased risk of autism was largely found in children of mothers reporting antidepressant use at the first antenatal interview. However, SSRIs as well as non-selective monoamine reuptake inhibitors were associated with increased risks for autism, suggesting non-SSRIs may not be “safer” alternatives in this context.
  • Associations were largely limited to autism without intellectual disability, suggesting that autism with and without intellectual disability may have partially different causes

What this study adds

 

 

Source: BMJ